Implementing NICE guidance

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1 Implementing NICE guidanceNocturnal enuresisImplementing NICE guidanceABOUT THIS PRESENTATION:This presentation has been written to help you raise awareness of the NICE clinical guideline on nocturnal enuresis. This guideline has been written for healthcare professionals and other staff who care for children and young people with bedwetting.The guideline is available in a number of formats, including a quick reference guide. You may want to hand out copies of the quick reference guide at your presentation so that your audience can refer to it. It is recommended that you refer your audience to page 13 of the quick reference guide which contains the initial treatment algorithm. See the end of the presentation for ordering details.You can add your own organisation’s logo alongside the NICE logo.We have included notes for presenters, broken down into ‘key points to raise’, which you can highlight in your presentation, and ‘additional information’ that you may want to draw on, such as a rationale or an explanation of the evidence for a recommendation. Where necessary, the recommendation will be given in full.DISCLAIMERThis slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.PROMOTING EQUALITYImplementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.October 2010NICE clinical guideline 111

2 What this presentation coversBackgroundScopeKey priorities for implementationCosts and savingsDiscussionFind out moreNOTES FOR PRESENTERS:In this presentation I will start by providing some background to the guideline and why it is important.I will then present the key priorities for implementation. The NICE guideline contains ten key priorities for implementation, which you can find on page 5 of your quick reference guide.Next, I will summarise the costs and savings that are likely to be incurred in implementing the guideline.Then I will open the meeting up with a list of questions to help prompt a discussion on local issues for incorporating the guidance into practice.Finally, the presentation will end with further information about the support provided by NICE.

3 BackgroundInvoluntary wetting during sleep without any inherent suggestions of frequency of bedwetting or pathophysiologyPrevalence decreases with ageCauses not fully understoodTreatment has a positive effect on the self-esteem of children and young people. Healthcare professionals should persist in offering treatmentsNOTES FOR PRESENTERS:Key points to raise:The term ‘bedwetting’ is used in this guideline to describe the symptom of involuntary wetting during sleep without any inherent suggestion of frequency of bedwetting or pathophysiology.Bedwetting is a widespread and distressing condition that can have a deep impact on a child or young person’s behaviour, emotional wellbeing and social life. It is also very stressful for the parents or carers. The prevalence of bedwetting decreases with age. Bedwetting less than 2 nights a week has a prevalence of 21% at about 4 and a half years and 8% at 9 and a half years. More frequent bedwetting is less common and has a prevalence of 8% at 4 and a half years and 1.5% at 9 and a half years1.The causes of bedwetting are not fully understood. Bedwetting can be considered to be a symptom that may result from a combination of different predisposing factors. There are a number of different disturbances of physiology that may be associated with the development of bedwetting. These disturbances may be categorised as sleep arousal difficulties, polyuria and bladder dysfunction. It also runs in families.Children and young people with bedwetting may also have symptoms related to the urinary tract during the day. A history of daytime urinary symptoms may be important in determining the approach to management of bedwetting and so the assessment sections include questions about daytime urinary symptoms and how the answers to these may influence the approach to managing bedwetting. However, the management of daytime urinary symptoms is outside the scope of this guideline.The treatment of bedwetting has a positive effect on the self-esteem of children. Healthcare professionals, working in a variety of settings, should persist in offering different treatments and treatment combinations if the first-choice treatment is not successful.The guideline will assume that prescribers will use a drug’s summary of product characteristics to inform decisions made with individual patients.References1. Butler RJ, Heron J (2008) The prevalence of infrequent bedwetting and nocturnal enuresis in childhood: A large British cohort. Scandinavian Journal of Urology and Nephrology 42: 257–64

4 ScopeRecommendations on the assessment and management of bedwetting in children and young people.Groups that are coveredNo minimum age limit for inclusion.Children and young people (including those with special needs) aged under 19 years who continue to have episodes of night-time bedwetting, with or without daytime urinary symptoms.NOTES FOR PRESENTERS:Key points to raise:This guideline makes recommendations on the assessment and management of bedwetting in children and young people.The guidance applies to children and young people up to 19 years with the symptom of bedwetting. Children are generally expected to be dry by a developmental age of 5 years, and historically it has been common practice to consider children for treatment only when they reach 7 years. In this guideline there is no minimum age limit to allow consideration of the benefit of interventions in younger children (under 7 years) previously excluded from treatment.Groups that are coveredChildren and young people aged under 19 years who continue to have episodes of night-time bedwetting, with or without daytime urinary symptoms.Children and young people aged under 19 years with special needs who continue to have night-time bedwetting with or without daytime urinary symptoms.Groups that are not coveredAdults aged 19 years or over with any form of incontinence.Children and young people who have daytime urinary incontinence only.

5 Key priorities for implementationThe key priorities for implementation can be classified into the following areas:Principles of careAssessment and investigationPlanning managementAdvice on fluid intake, diet and toileting patternsReward systemsInitial treatment – alarmsInitial treatment – desmopressinLack of response to initial treatment optionsNOTES FOR PRESENTERS:The NICE guideline contains 99 recommendations about how care can be improved, but the experts who wrote the guideline have chosen key recommendations that they think will have the greatest impact on care and are the most important priorities for implementation.They are divided into the eight areas of key priority shown on the slide and within these there are a total of ten recommendations. Some recommendations which are related to the key priorities for implementation will be displayed in the associated notes sections, and where it is felt that non key priority recommendations are essential to the understanding of the whole pathway of care, they will appear on a slide.Key priority recommendations will be labelled KPI

6 Principles of careInform children and young people with bedwetting and their parents or carers that it is not the child or young person’s fault and that punitive measures should not be used in the management of bedwetting (KPI)Offer tailored support, assessment and treatment to all children and young people with bedwetting and their parents or carers (KPI)Do not exclude younger children (for example, those under 7 years) from the management of bedwetting on the basis of age alone (KPI)NOTES FOR PRESENTERS:Recommendations in full:Inform children and young people with bedwetting and their parents or carers that bedwetting is not the child or young person's fault and that punitive measures should not be used in the management of bedwetting. [1.1.1]Offer support, assessment and treatment tailored to the circumstances and needs of the child or young person and parents or carers. [1.1.2]Do not exclude younger children (for example, those under 7 years) from the management of bedwetting on the basis of age alone. [1.1.3]Related recommendations:Perform regular medication reviews for children and young people on repeated courses of drug treatment for bedwetting. [1.1.4]

7 Assessment and investigation: 1History takingAsk about onset of bedwetting, pattern of bedwetting, daytime symptoms, toileting patterns, fluid intake and practical issues.Assess for comorbidities and other factors that may be associated with bedwetting.NOTES FOR PRESENTERS:These are not key priority recommendations but have been included because they are important to ensure the child or young person received the appropriate treatment.Recommendations in full:Ask whether the bedwetting started in the last few days or weeks. If so, consider whether this is a presentation of a systemic illness. [1.3.1]Ask if the child or young person had previously been dry at night without assistance for 6 months. If so, enquire about any possible medical, emotional or physical triggers, and consider whether assessment and treatment is needed for any identified triggers. [1.3.2]Ask about the pattern of bedwetting, including questions such as: how many nights a week does bedwetting occur, how many times a night does bedwetting occur, does there seem to be a large amount of urine, at what times of night does the bedwetting occur, does the child or young person wake up after bedwetting? [1.3.3]Ask about the presence of daytime symptoms in a child or young person with bedwetting, including: daytime frequency (that is, passing urine more than seven times a day), daytime urgency, daytime wetting, passing urine infrequently (fewer than four times a day), abdominal straining or poor urinary stream, pain passing urine. [1.3.4]Ask about daytime toileting patterns in a child or young person with bedwetting, including: whether daytime symptoms occur only in some situations, avoidance of toilets at school or other settings, whether the child or young person goes to the toilet more or less frequently than his or her peers. [1.3.5]Ask about the child or young person's fluid intake throughout the day. In particular, ask whether the child or young person, or the parents or carers are restricting fluids. [1.3.6]Assess whether the child or young person has any comorbidities or there are other factors to consider, in particular:constipation and/or soilingdevelopmental, attention or learning difficultiesdiabetes mellitusbehavioural or emotional problemsfamily problems or vulnerable child or family. [1.3.9]See pages 6-8 of the quick reference guide for more details about assessment and investigation

8 Assessment and investigation: 2Discuss with the parents or carers whether they need support, particularly if they are having difficulty coping with the burden of bedwetting, or if they are expressing anger, negativity or blame towards the child or young person (KPI)Consider assessment, investigation and/or referral when bedwetting is associated withsevere daytime symptomsa history of recurrent urinary infectionsknown or suspected physical or neurological problemscomorbidities or other factorsNOTES FOR PRESENTERS:Recommendations in full:Recommendation is shown in full on the slide. (bullet 1)Consider assessment, investigation and/or referral when bedwetting is associated with:severe daytime symptomsa history of recurrent urinary infectionsknown or suspected physical or neurological problemscomorbidities or other factors (for example, those listed in recommendation ).[1.3.10]Related recommendations:Discuss factors that might affect treatment and support needs, such as:sleeping arrangements (for example, does the child or young person have his or her own bed or bedroom)the impact of bedwetting on the child or young person and familywhether the child or young person and parents or carers have the necessary level of commitment, including time available, to engage in a treatment programme.[1.3.16]See page of the quick reference guide for more details about assessment and investigation

9 Planning managementExplain the condition and possible treatments with the child or young person and parents or carersClarify what the child or young person and parents or carers hope the treatment will achieveExplore the child or young person’s views about their bedwettingConsider whether or not it is appropriate to offer alarm or drug treatment, depending on the age of the child or young person, the frequency of bedwetting and the motivation and needs of the child or young person and their family (KPI)NOTES FOR PRESENTERS:Recommendations in full:Explain the condition, the effect and aims of treatment, and the risks and benefits of the possible treatments to the child or young person and parents or carers (see recommendations and ). [1.4.1]Clarify what the child or young person and parents or carers hope the treatment will achieve. Ask whether short-term dryness is a priority for family or recreational reasons (for example, for a sleep-over). [1.4.2]Explore the child or young person’s views about their bedwetting, including:what they think the main problem iswhether they think the problem needs treatment. [1.4.3]Recommendation is shown in full on the slide. (Bullet 4)Related recommendations:Explore and assess the ability of the family to cope with using an alarm for the treatment of bedwetting. [1.4.4]See page 9 of the quick reference guide for more details about planning management

10 Advice on fluid intake, diet and toileting patternsAddress excessive or insufficient fluid intake or abnormal toileting patterns before starting other treatment for bedwetting in children and young people (KPI)Adequate daily fluid intake is importantAgeSexTotal drinks per day4 – 8 yearsFemaleMale1000 – 1400 ml9 – 13 years1200 – 2100 ml1400 – 2300 ml14 – 18 years1200 – 2500 ml2100 – 3200 mlNOTES FOR PRESENTERS:Recommendations in full:Recommendation is shown in full on the slide. (Bullet 1)Advise children and young people with bedwetting and their parents or carers that:adequate daily fluid intake is important in the management of bedwettingdaily fluid intake varies according to ambient temperature, dietary intake and physical activity. A suggested intake of drinks is given in table 2 (see slide). [1.5.1]Related recommendations:Advise the child or young person and parents or carers that the consumption of caffeine-based drinks should be avoided in children and young people with bedwetting. [1.5.2]Advise the child or young person and parents or carers to eat a healthy diet and not to restrict diet as a form of treatment for bedwetting. [1.5.3]Advise the child or young person of the importance of using the toilet at regular intervals throughout the day. [1.5.4]Advise parents or carers to encourage the child or young person to use the toilet to pass urine at regular intervals during the day and before sleep (typically between four and seven times in total). This should be continued alongside the chosen treatment for bedwetting. [1.5.5]Suggest a trial without nappies or pull-ups for a child or young person with bedwetting who is toilet trained by day and is wearing nappies or pull-ups at night. Offer advice on alternative bed protection to parents and carers. [1.5.7]See pages 10 – 11 of the quick reference guide for more details about offering information and advice to the child or young person and family

11 Reward systemsExplain that reward systems with positive rewards for agreed behaviour rather than dry nights should be used either alone or in conjunction with other treatments for bedwetting (KPI)Inform parents or carers that they should not use systems that penalise or remove previously gained rewardsAdvise parents or carers to try a reward system alone for the initial treatment of bedwetting in young children who have some dry nightsNOTES FOR PRESENTERS:Recommendations in full:Explain that reward systems with positive rewards for agreed behaviour rather than dry nights should be used either alone or in conjunction with other treatments for bedwetting. For example, rewards may be given for:drinking recommended levels of fluid during the dayusing the toilet to pass urine before sleepengaging in management (for example, taking medication or helping to change sheets). [1.7.1]Recommendation is shown in full on the slide. (Bullet 2)Advise parents or carers to try a reward system alone (as described in recommendation 1.7.1) for the initial treatment of bedwetting in young children who have some dry nights. [1.7.3]

12 Initial treatment: alarms Who to considerOffer an alarm as the first-line treatment to children and young people whose bedwetting has not responded to advice on fluids, toileting or an appropriate reward system, unless the alarm is inappropriate or undesirable.Alarm may be inappropriate when:bedwetting is very infrequent (that is, less than 1–2 wet beds per week)the parents or carers are having emotional difficulty coping with the burden of bedwettingthe parents or carers are expressing anger, negativity or blame towards the child or young personNOTES FOR PRESENTERS:Recommendation in full:Offer an alarm as the first-line treatment to children and young people whose bedwetting has not responded to advice on fluids, toileting or an appropriate reward system, unless:- an alarm is considered undesirable to the child or young person or their parents or carers or- an alarm is considered inappropriate, particularly if:bedwetting is very infrequent (that is, less than 1–2 wet beds per week)the parents or carers are having emotional difficulty coping with the burden of bedwettingthe parents or carers are expressing anger, negativity or blame towards the child or young person. [1.8.1]Related recommendations:Do not exclude alarm treatment as an option for bedwetting in children and young people with:daytime symptoms as well as bedwettingsecondary bedwetting. [1.8.5]Consider an alternative type of alarm (for example, a vibrating alarm) for the treatment of bedwetting in children and young people who have a hearing impairment. [1.8.6]Consider an alarm for the treatment of bedwetting in children and young people with learning difficulties and/or physical disabilities. Tailor the type of alarm to each individual's needs and abilities. [1.8.7]Consider an alarm for the treatment of bedwetting in children under 7 years, depending on their ability, maturity, motivation and understanding of the alarm. [1.8.8]These recommendations are closely linked to recommendation and in the planning management slide (slide 9)See the initial treatment pathway on page 13, which covers who should receive alarm treatment.

13 Initial treatment: alarms Information needsEnsure that advice and support are available.Inform children and young people and their parents or carers about:the benefits of combining alarm treatment with a reward systemthe high long-term success rate of alarm treatmentthe aims of alarm treatmentpractical issues for using the alarm (such as impact on sleep, commitment needed)the early and late signs of response.NOTES FOR PRESENTERS: These are not key priority recommendations but have been included because they are important to ensuring the success of the alarm:Inform children and young people and parents or carers about the benefits of alarms combined with reward systems. Advise on the use of positive rewards for desired behaviour, such as waking up when the alarm goes off, going to the toilet after the alarm has gone off, returning to bed and resetting the alarm. [1.8.9]Encourage children and young people with bedwetting and their parents or carers to discuss and agree on their roles and responsibilities for using the alarm and the use of rewards. [1.8.10]Ensure that advice and support are available to children and young people and their parents or carers who are given an alarm, and agree how these should be obtained. Be aware that they may need a considerable amount of help in learning how to use an alarm. [1.8.11]Inform the child or young person and their parents or carers that the aims of alarm treatment for bedwetting are to train the child or young person to: recognise the need to pass urine, wake to go to the toilet or hold on, learn over time to hold on or to wake spontaneously and stop wetting the bed. [1.8.12]Inform the child or young person and their parents or carers that:alarms have a high long-term success rate, using an alarm can disrupt sleep, that parents or carers may need to help the child or young person to wake to the alarm, using an alarm requires sustained commitment, involvement and effort from the child or young person and their parents or carers, they will need to record their progress (for example, if and when the child or young person wakes and how wet they and the bed are) and alarms are not suitable for all children and young people and their families. [1.8.13]If offering an alarm for bedwetting, inform the child or young person and their parents or carers how to:set and use the alarm, respond to the alarm when it goes off, maintain the alarm, deal with problems with the alarm, including who to contact when there is a problem, return the alarm when they no longer need it. [1.8.14]Inform the child or young person and their parents or carers that it may take a few weeks for the early signs of a response to the alarm to occur and that these may include: smaller wet patches, waking to the alarm, the alarm going off later and fewer times per night, fewer wet nights. [1.8.15]Inform the child or young person and their parents or carers that dry nights may be a late sign of response to the alarm and may take weeks to achieve. [1.8.16]Inform the parents or carers that they can restart using the alarm immediately, without consulting a healthcare professional, if the child or young person starts bedwetting again following a response to alarm treatment. [1.8.17]See pages 14 and 15 of the quick reference guide for information about alarm treatment.

14 Initial treatment: desmopressinOffer desmopressin to children and young people over 7 years, if:rapid-onset and/or short-term improvement in bedwetting is the priority of treatment oran alarm is inappropriate or undesirable (see recommendation 1.8.1)NOTES FOR PRESENTERS:Recommendations in full:Recommendation is shown in full on the slide. (Bullet 1). See slide 12 for more information about when an alarm is inappropriateIn children and young people who have failed to achieve complete dryness after 1 to 2 weeks of the initial dose of desmopressin (200 micrograms for Desmotabs or 120 micrograms for DesmoMelt), consider increasing the dose (to 400 micrograms for Desmotabs or 240 micrograms for DesmoMelt). [1.10.4]If offering desmopressin for bedwetting, inform the child or young person and their parents or carers:that many children and young people, but not all, will experience a reduction in wetnessthat many children and young people, but not all, will relapse when treatment is withdrawnhow desmopressin worksof the importance of fluid restriction from 1 hour before until 8 hours after taking desmopressinthat it should be taken at bedtimeif appropriate, how to increase the dose if there is an inadequate response to the starting doseto continue treatment with desmopressin for 3 monthsthat repeated courses of desmopressin can be used. [1.10.9]Related recommendations:Consider desmopressin for children aged 5–7 years if treatment is required and:rapid-onset and/or short-term improvement in bedwetting is the priority of treatment oran alarm is inappropriate or undesirable (see recommendation 1.8.1, slide 12). [1.10.2]Assess the response to desmopressin at 4 weeks and continue treatment for 3 months if there are signs of a response. Consider stopping if there are no signs of response. Signs of response include: smaller wet patches, fewer wetting episodes per night, fewer wet nights. [1.10.5]Consider advising that desmopressin should be taken 1–2 hours before bedtime in children and young people with bedwetting that has either partially responded or not responded to desmopressin taken at bedtime. Ensure that the child or young person can comply with fluid restriction starting from 1 hour before the drug is taken. [ ]Consider continuing treatment with desmopressin for children and young people with bedwetting that has partially responded, as bedwetting may improve for up to 6 months after starting treatment. [ ]See page 13 and 16 of the quick reference guide for more information about desmopressin treatment

15 Desmopressin: other factorsDo not exclude desmopressin as an option for the management of bedwetting in children and young people:who also have daytime symptoms. However, do not use in only daytime wettingwith sickle cell disease*with emotional, attention or behavioural problems or developmental or learning difficulties*.Do not routinely measure weight, serum electrolytes, blood pressure or serum osmolality.* If they can comply with night time fluid restriction.NOTES FOR PRESENTERS:These are not key priorities but have been included to highlight the important points to consider when treating bedwetting with desmopressinRecommendations in full:Do not exclude desmopressin as an option for the management of bedwetting in children and young people who also have daytime symptoms. However, do not use desmopressin in the treatment of children and young people who only have daytime wetting. [1.10.3]Do not exclude desmopressin as an option for the treatment of bedwetting in children and young people with sickle cell disease if an alarm is inappropriate or undesirable and they can comply with night-time fluid restriction. Provide advice about withdrawal of desmopressin at times of sickle cell crisis. [1.10.6]Do not exclude desmopressin as an option for the treatment of bedwetting in children and young people with emotional, attention or behavioural problems or developmental and learning difficulties if an alarm is inappropriate or undesirable and they can comply with night-time fluid restriction. [1.10.7]Do not routinely measure weight, serum electrolytes, blood pressure and urine osmolality in children and young people being treated with desmopressin for bedwetting. [1.10.8]

16 Lack of response to initial treatmentRefer children and young people with bedwetting that has not responded to courses of treatment with an alarm and/or desmopressin for further review and assessment of factors that may be associated with a poor response, such as an overactive bladder, an underlying disease or social and emotional factors (KPI)NOTES FOR PRESENTERS:Recommendation is shown in full on the slide.Related recommendations:These cover children and young people experiencing lack of response to alarm treatment or recurrence of bedwetting.If bedwetting does not respond to initial alarm treatment, offer:combination treatment with an alarm and desmopressin ordesmopressin alone if continued use of an alarm is no longer acceptable to the child or young person or their parents and carers. [1.9.1]Offer desmopressin alone to children and young people with bedwetting if there has been a partial response to a combination of an alarm and desmopressin following initial treatment with an alarm. [1.9.2]Consider alarm treatment again if a child or young person who was previously dry with an alarm has started regularly bedwetting again. [1.11.1]Offer combination treatment with an alarm and desmopressin to children and young people who have more than one recurrence of bedwetting following successful treatment with an alarm. [1.11.2]Consider using repeated courses of desmopressin for children and young people with bedwetting that has responded to desmopressin treatment but who experience repeated recurrences. Withdraw desmopressin treatment at regular intervals (for 1 week every 3 months) to check if dryness has been achieved when using it for the long-term treatment of bedwetting. [1.11.3]Gradually withdraw desmopressin rather than suddenly stopping it if a child or young person has had a recurrence of bedwetting following response to previous desmopressin treatment courses. [1.11.4]Consider alarm treatment as an alternative to continuing treatment for children and young people who have recurrences of bedwetting if an alarm is now considered appropriate and desirable. [1.11.5]

17 Other recommendation areasLifting and wakingAnticholingericsTricyclicsTraining programmes for the management of bedwettingChildren under 5 years with bedwettingNOTES FOR PRESENTERS:These are not key priorities but have been included to ensure understanding of all of the areas covered in this guideline.The guideline also contains further recommendations within the areas of:Lifting and waking: recommendation see the NICE guideline for the recommendation in full or page 11 of the quick reference guide for more informationAnticholingerics: recommendations – see the NICE guideline for the recommendation in full or page 18 of the quick reference guide for more informationTricyclics: recommendations – see the NICE guideline for the recommendation in full or page 19 of the quick reference guide for more informationTraining programmes for the management of bedwetting: recommendations – see the NICE guideline for the recommendations in full or page 11 of the quick reference guide for more informationChildren under 5 years with bedwetting: recommendations – see the NICE guideline for the recommendation in full or page 12 of the quick reference guide for more information

18 Costs and savingsThe guideline on nocturnal enuresis is unlikely to result in a significant change in resource use in the NHS. However, recommendations in the following areas may result in additional costs/savings depending on local circumstances:Offering an alarm as first-line treatmentUsing combination treatment with alarm and desmopressin when there has been no response to initial treatment with an alarmOffering desmopressinTraining of healthcare professionalsConsidering imipramine if there is no response to any other treatmentsNOTES FOR PRESENTERS:NICE has found that implementing this guideline is unlikely to result in any significant changes in resource use, based on national assumptions. The number of patients involved is small and practice varies significantly across the country. Organisations should evaluate their services and assess heir costs locally based on the following recommendations.Offering an alarm as first line treatment [1.8.1] There might be additional costs for alarms as the guideline recommends that alarms are now considered for children under 7 years who may have previously not received treatment. The NICE guidance specifically states in recommendation not to deny treatment because of age alone. Using combination treatment when there has been no response to initial treatment with an alarm [1.9.1]Clinical opinion is that combination treatment with an alarm and desmopressin is not commonly used in practice. Therefore, if combination treatments are increasingly used they might have a cost implication locally.Offering desmopressin [ and ]The number of children and young people in whom an alarm is inappropriate or undesirable is likely to be small at a national level. Therefore, local organisations are encouraged to assess their own costs based on local circumstances and needs.Training of healthcare professionalThere may be an increase in the number of staff required to administer and treat more patients including referrals to specialists. This will also increase the amount and level of training required.Considering imipramine if there is no response to any other treatments [1.14.3]Feedback from the GDG revealed that there is very little prescription of imipramine for bedwetting in children and young people in the NHS. Imipramine treatment should be considered only if children and young people have not responded to any other treatments and they have been assessed by a healthcare professional with expertise in the management of bedwetting that has not responded to an alarm and/or desmopressin. The number of patients is likely to be very small. Therefore, the cost would be insignificant at a national level.

19 DiscussionHow can alarms be accessed for children who meet the criteria? How can we ensure enough alarms are available to meet local needs?How can we ensure that the service is well integrated and that the team have a good awareness and understanding of the guideline?Who would prescribe the medications recommended?How can we provide the information recommended to parents and carers, including how to take desmopressin?NOTES FOR PRESENTERS:These questions are suggestions that have been developed to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation.Additional questions:AlarmsWho purchases the alarms? Should we purchase one type of alarm or a variety?How much do the alarms cost?Are alarms maintained in a cost effective way. For example, are there robust arrangements for repair and quick replacement to avoid interrupting the treatment programme?Care pathwaysDo we have robust referral pathways in place?Do we have robust arrangements for follow up of patients after initial assessment and after discharge?Do we have a system whereby patients can access appointments after discharge if a relapse occurs?If the answer is no to any of these questions, what can we do to establish these systems?

20 Find out more Visit www.nice.org.uk/guidance/CG111 for: the guidelinethe quick reference guide‘Understanding NICE guidance’costing statement and templateaudit supportbaseline assessment toolguide to resources (also includes childhood constipation)commissioning guideNOTES FOR PRESENTERS:You can download the guidance documents from the NICE website.The NICE guideline – all the recommendations.A quick reference guide – a summary of the recommendations for healthcare professionals.‘Understanding NICE guidance’ – information for patients and carers.The full guideline – all the recommendations, details of how they were developed, and reviews of the evidence they were based on.For printed copies of the quick reference guide or ‘Understanding NICE guidance’, phone NICE publications on or and quote reference numbers N2318 (quick reference guide) and/or N2319 (‘Understanding NICE guidance’).NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website.Costing tools – a costing statement details of the likely costs and savings when the cost impact of the guideline is not considered to be significant and a costing template allows you to estimate the local costs and savings involved.Audit support – for monitoring local practice.Baseline assessment tool - to help identify which areas of practice may need more support, decide on clinical audit topics and prioritise implementation activities.Guide to resources – to signpost healthcare professionals, patients, families and carers to online resources that will help implement the recommendations in this guideline.Commissioning guide - can be used to anticipate local service demand and estimate the cost of local commissioning decisions.